Wednesday, May 03, 2006

In the May 2, 2006 issue of the Annals of Internal Medicine, Dr. Ashok V. Daftary in a letter to the editor blames academic medicine for much in the unfolding saga for the demise of internal medicine.

He writes:

"Academic medicine is the carpenter that fashioned the coffin of internal medicine.Instead of reengineering internal medicine to accommodate changes, it cannibalized the discipline by reducing its worth, creating the hospitalist and ambulatory care internist. These were both nails that helped seal the coffin; the former reduced the influence of the internist in the acute care environment and the latter blurred distinctions between internists and those without medical degrees who practice in the ambulatory settings."

"...absent an identity, the internist's only remaining role is thought to be that of provider of ambulatory care to chronically ill whose medical problems are beyond procedural intervention and lucrative compensation."

I do not know the relative contributions of academia and managed care to the birth and growth of the hospitalist phenomenon but my default position is to always blame managed care. The "follow-the money" rule does not always lead to the right answer but that it where the smart money bets. I think at most some academic and "thought leader" internists were complicit.

I believe, though, that the recommendations to change the IM residency program to allow (or encourage?) the third year residents to opt to do more in patient or more out patient training-based on their future plans will only make worse the schism betweeen the hospital internist and the "officist" and do little to lessen the increasing fragmentation of medical care. And the idea that an IM resident could do the training, opt to be a office doctor and never -after the residency-take care of patients with complicated serious ilnesses in the hospital is so contrary to what a internist is (used to be ?) all about.